Fredric M. Hustey

Quality Indicators for Geriatric Emergency Care

OBJECTIVES Emergency departments (EDs), similar to other health care environments, are concerned with improving the quality of patient care. Older patients comprise a large, growing, and particularly vulnerable subset of ED users. The project objective was to develop ED-specific quality indicators for older patients to help practitioners identify quality gaps and focus quality improvement efforts. METHODS The Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, including members representing the American College of Emergency Physicians (ACEP), selected three conditions where there are quality gaps in the care of older patients: cognitive assessment, pain management, and transitional care in both directions between nursing homes and EDs. For each condition, a content expert created potential quality indicators based on a systematic review of the literature, supplemented with expert opinion when necessary. The original candidate quality indicators were modified in response to evaluation by four groups: the Task Force, the SAEM Geriatric Interest Group, and audiences at the 2007 SAEM Annual Meeting and the 2008 American Geriatrics Society Annual Meeting. RESULTS The authors offer 6 quality indicators for cognitive assessment, 6 for pain management, and 11 for transitions between nursing homes and EDs. CONCLUSIONS These quality indicators will help researchers and clinicians target quality improvement efforts. The next steps will be to test the feasibility of capturing the quality indicators in existing medical records and to measure the extent to which each quality indicator is successfully met in current emergency practice.

A Brief Risk Stratification Tool to Predict Functional Decline in Older Adults Discharged from Emergency Departments

OBJECTIVES: To determine the effectiveness of the six‐item Triage Risk Screening Tool (TRST) to assess baseline functional status and predict subsequent functional decline in older community‐dwelling adults discharged home from the emergency department (ED).

High Yield Research Opportunities in Geriatric Emergency Medicine: Prehospital Care, Delirium, Adverse Drug Events, and Falls

Emergency services constitute crucial and frequently used safety nets for older persons, an emergency visit by a senior very often indicates high vulnerability for functional decline and death, and interventions via the emergency system have significant opportunities to change the clinical course of older patients who require its services. However, the evidence base for widespread employment of emergency system-based interventions is lacking. In this article, we review the evidence and offer crucial research questions to capitalize on the opportunity to optimize health trajectories of older persons seeking emergency care in four areas: prehospital care, delirium, adverse drug events, and falls.

The Six-item Screener to Detect Cognitive Impairment in Older Emergency Department Patients

BACKGROUND Cognitive impairment due to delirium or dementia is common in older emergency department (ED) patients. To prevent errors, emergency physicians (EPs) should use brief, sensitive tests to evaluate older patients mental status. Prior studies have shown that the Six-Item Screener (SIS) meets these criteria. OBJECTIVES The goal was to verify the performance of the SIS in a large, multicenter sample of older ED patients. METHODS A prospective, cross-sectional study was conducted in three urban academic medical center EDs. English-speaking ED patients > or = 65 years old were enrolled. Patients who received medications that could affect cognition, were too ill, were unable to cooperate, were previously enrolled, or refused to participate were excluded. Patients were administered either the SIS or the Mini-Mental State Examination (MMSE), followed by the other test 30 minutes later. An MMSE of 23 or less was the criterion standard for cognitive impairment; the SIS cutoff was 4 or less for cognitive impairment. Standard operator characteristics of diagnostic tests were calculated with 95% confidence intervals (CIs), and a receiver operating characteristic curve was plotted. RESULTS The authors enrolled 352 subjects; 111 were cognitively impaired by MMSE (32%, 95% CI = 27% to 37%). The SIS was 63% sensitive (95% CI = 53% to 72%) and 81% specific (95% CI = 75% to 85%). The area under the receiver operating characteristic curve was 0.77 (95% CI = 0.72 to 0.83). CONCLUSIONS The sensitivity of the SIS was lower than in prior studies. The reasons for this lower sensitivity are unclear. Further study is needed to clarify the ideal brief mental status test for ED use.

Acute quetiapine poisoning

Quetiapine (Seroquel) is a member of a new class of antipsychotic agents used in the treatment of schizophrenia. Its pharmacologic effect is primarily mediated via antagonistic binding to serotonergic (5HT2) and dopaminergic (D2) receptors. Presented is a case of acute quetiapine overdose in a patient with associated tachycardia, hypotension, prolonged QTc, and rapid progression to coma. Management included activated charcoal, i.v. saline, and intubation for airway protection. The patients mental status rapidly improved within several hours of the ingestion, and the prolonged QTc and tachycardia resolved by the second and third days of hospitalization, respectively, without further intervention. This case illustrates the potential for hemodynamic instability and sudden deterioration in level of consciousness, warranting close monitoring and early intubation for airway protection. All patients with acute quetiapine overdose requiring hospitalization should be admitted to an intensive care unit setting.

An internet-based communication network for information transfer during patient transitions from skilled nursing facility to the emergency department.

OBJECTIVES: To determine whether the implementation of an Internet‐based communication system improves the amount of essential information conveyed between a skilled nursing facility (SNF) and the emergency department (ED) during patient care transitions.

Potentially inappropriate medications and adverse drug effects in elders in the ED

The objective of this study was to examine the prevalence of potentially inappropriate medications (PIMs) and potential adverse drug effects (ADEs) in older adults presenting to the emergency department (ED). This was a prospective observational study of a convenience sample of adults 65 years and older presenting to the ED at an urban, tertiary care hospital. Potentially inappropriate medications were defined according to 2003 Beers criteria. Potential ADEs were defined as either (1) a potential drug-drug interaction, (2) alternative medication likely to cause toxicity or drug interactions, or (3) toxic doses of vitamins or minerals. Of 174 eligible patients, 124 were enrolled. The mean number of medications used per patient was 8.6 (range, 0-20). Thirty six patients (29%, 95% confidence interval, 27%-37%) presented to the ED with at least one PIM. Eight PIMs were prescribed in the ED, representing 16% of all prescriptions in the ED. Potential ADEs meeting the defined criteria were found in 26.6% of patients. A subanalysis of a random sample of charts revealed significant discordance between medication lists obtained by the research assistants and that of the health care providers. Older ED patients are at high risk for use of potentially inappropriate medications and ADEs. This problem may be magnified by inaccurate medication lists obtained by ED providers. A larger multicenter study may help to better define the scope of this problem.

Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis

Objective: To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance. Methods: We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014–November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges. Results: Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset. Conclusion: Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.

Implementing an Internet-Based Communication Network for Use during Skilled Nursing Facility to Emergency Department Care Transitions: Challenges and Opportunities for Improvement

OBJECTIVES To explore the feasibility of implementing an Internet-based communication network for communication of health care information during skilled nursing facility (SNF)-to-ED care transitions, and to identify potential barriers to system implementation. METHODS Qualitative. SETTING The largest SNF affiliated with the ED of an urban tertiary care center. PARTICIPANTS Consecutive sample of all patients transferred from SNF to ED over 8 months between June 2007 and January 2008; ED and SNF care providers. INTERVENTION The development and implementation of an Internet-based communication network for use during SNF-to-ED care transitions. This network was developed by adapting a preexisting Internet-based system that is widely used to facilitate placement of hospitalized patients into SNFs. Internet-based SNF and ED surveys were used to help identify barriers to implementation. RESULTS There were 276/276 care transitions reviewed. The Internet-based communication network was used in 76 (28%) care transitions, with usage peaking at 40% near the end of the study. Barriers to success that were identified included lack of an electronic medical record (EMR) at the SNF; pervasive negative attitudes between ED and SNF personnel; time necessary for network use during care transitions; frustration by emergency physicians at low system usage rates by SNF personnel; and additional login requirements by ED personnel. CONCLUSIONS Although implementing an Internet-based network for nursing home to ED communication may be feasible, significant barriers were identified in this study that are likely generalizable to other health care settings. Understanding such barriers is an essential first step toward building successful electronic communication networks in the future.

Decreasing door-to-balloon times via a streamlined referral protocol for patients requiring transport

PURPOSES The objective of this study was to evaluate the effectiveness of a streamlined interfacility referral protocol in reducing door-to-balloon (D2B) times for patients experiencing acute ST-segment elevation myocardial infarction (STEMI). BASIC PROCEDURES In a retrospective database review, we compared D2B times for patients requiring interfacility transfer after the implementation of a streamlined referral protocol. All patients undergoing interfacility transport with a referring diagnosis of STEMI were eligible for inclusion. Quality management databases were reviewed by trained abstractors using standardized data entry forms for D2B times from July 2009 through June 2010. Median D2B times with interquartile ranges are reported. MAIN FINDINGS A total of 133 patients exhibited complete data and were included in the analysis, 54 of which were transferred via the streamlined referral protocol. Streamlined referral patients exhibited a median D2B time of 101 minutes (interquartile range, 88-128) vs a median D2B time of 122 minutes (interquartile range, 99-157) for the traditional referral group (P = .001). Door-to-balloon times of 90 minutes or less were achieved in 13% of the traditional referral patients and in 30% of the streamlined protocol group (odds ratio, 2.9; 95% confidence interval, 1.2-7). PRINCIPAL CONCLUSION The implementation of a streamlined referral protocol has significantly reduced D2B times for patients diagnosed with STEMI that required interfacility transport for intervention.